COMPARISON OF THE INCIDENCE OF ACUTE WATERY DIARRHEA IN CHILDREN AGED 0-

12 YEARS WITH EXCLUSIVE BREASTFEEDING AND INFANT FORMULA MILK

Adrianus Andri1
1
Borong Public General Hospital, East Nusa Tenggara, Indonesia

Corresponding Author: Adrianus Andri. Borong Public General Hospital

E-mail : Adrianusandri100@gmail.com

Received 07 September 2023; Accepted 28 September 2023; Online Published 20 Oktober 2023

Abstract

Background: This study aimed to compare the incidence of acute watery diarrhea in children aged
0-12 years between exclusive breastfeeding compared to formula milk and diarrhea incidence in
Borong Regional Public Hospital, Indonesia. Method: This was a cross-sectional design study with
a sample size of 60 infants. Information was obtained through interviews and medical record when
admission. Univariate data were presented in distribution frequency table form and bivariate analysis
data were analyzed by using Mann-Whitney test. Results: The incidence of diarrhea in children aged
0-12 years was dominated by children who consumed formula milk (68.3%) from the total study
sample. The results also found that there was a nonsignificant difference between exclusive
breastfeeding compared to infant formula milk and the incidence of diarrhea in infants under 1 year
of age. Conclusion: The incidence of diarrhea was lower among infants with exclusive breastfeeding
compared to infants with formula milk, although the difference is insignificant.

Keywords: outcome, microbiota, newborn

INTRODUCTION: months of life may prevent 2.5 million

Particularly in less developed
countries, diarrheal illness affects children
regularly. Poor feeding practices, such as the
early introduction of supplemental feeding and
poor hygiene, are usually implicated.
Understanding the link between eating habits
and diarrhea is crucial for properly preventing
and treating illness in children.1
Probiotics and bioactive compounds
found in human breast milk have been shown
to offer protection, hasten the maturity of the
neonatal intestinal mucosa, and support
systemic immunity. One of the best therapies
to prevent baby diarrhea is exclusive
breastfeeding (EBF). Globally, it is predicted
that EBF administered during the first six
instances of gastrointestinal infections (GI).2
The best feeding strategy for newborns
is generally accepted to be breastfeeding,
which offers several health advantages to both
the mother and the child. Direct breastfeeding,
which is the practice of providing a newborn
with only breast milk and no other food or
liquid, is crucial throughout the first six
months of life. However, the practice of
exclusive breastfeeding still encounters
difficulties despite the benefits that are known
to exist. It has been discovered that a mother's
decision to give her baby formula milk instead
of exclusively breastfeeding is influenced by
factors like maternal education, healthcare
provider support, and formula milk
marketing.3

3672
 A study that was published in the
Jurnal Ilmiah Kesehatan Diagnosis found a
link between formula feeding and the
likelihood of newborns developing diarrhea.
According to the study, infants who are
exclusively breastfed had a lower risk of
developing diarrhea than those who are
provided formula milk. This is so that bacteria
that can cause diarrhea don't thrive, which is
why formula milk preparation and hygiene are
necessary.4
Therefore, it's critical to comprehend
how feeding habits affect a baby's likelihood
of developing diarrhea. If direct breastfeeding
is not possible, it is crucial to recognize if
formula feeding is totally prohibited or if it is
a viable option. The purpose of this study was
to examine the connection between infants'
incidence of diarrhea with either exclusive
breastfeeding or formula milk.
METHOD:
This study was carried out at the
Borong Regional Public Hospital in the
Indonesian province of East Nusa Tenggara.
The number of newborns in the sample was
60. Infants younger than 12 months old who
were admitted to Borong Regional Public
Hospital meet the inclusion criteria. Infants
with serious illnesses or chronic diarrhea,
infants with low birth weights, and infants
Minimu Maximu
N m
Age 60 1 12
Valid N
60
(listwise)
Table 1. Descriptive Statistics
whose previous pregnancies were less than 37
weeks are all excluded. Acute diarrhea is a
condition marked by recurrent, more than
three times per day, liquid-containment bowel
movements that last fewer than 14 days.
Exclusive breastfeeding refers to nursing only
from the mother's breast, without additional
food or liquids.
Information was gathered from the
patient's medical record. Data was collected
from January to July 2023. The infants'
feeding habits, such as whether they were
solely breastfed or given formula milk, as well
as whether they experienced diarrhea, were
determined from their medical records.
Frequency distribution tables are used to
present univariate data, and the chi square test
is used to perform bivariate data analysis.
Bivariate data analysis is carried out using the
chi square test, and univariate data are
presented as frequency distribution tables. The
statistical program SPSS 23.0 was used to
conduct the data analysis.
RESULTS:
The results of this study showed that
the incidence of watery diarrhea in children
mostly occurred in the average child aged 6
years as shown in Table 1. The sex
distribution in this study was also not too
much different (Male: 32 subjects, Female: 28
subjects) as attached to Table 2.
Std.
m Mean Deviation
6.78 3.655
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 Frequenc Valid Cumulative
y Percent Percent Percent
Valid Female 28 46.7 46.7 46.7
Male 32 53.3 53.3 100.0
Total 60 100.0 100.0
Table 2. Gender Distribution

In Table 3, it can be seen that the incidence of
diarrhea in children aged 0-12 years is
dominated by infants who consume formula
milk (68.3% in infants who consume formula
milk). Based on these data, a statistical
analysis test was carried out with the Mann-
Whitney test and obtained a value of p =
0.144. The p value is <0.05 so that it can be
stated that there is insignificant difference in
the incidence of watery diarrhea in children
aged 0-12 years who consume breast milk or
formula milk (Table 4).

Frequenc Valid Cumulative

y Percent Percent Percent
Valid Breastfeedin
19 31.7 31.7 31.7
g
Formula
41 68.3 68.3 100.0
Milk
Total 60 100.0 100.0
Table 3. Feeding Practice

Age
Mann-Whitney U 298.000
Wilcoxon W 1159.000
Z -1.462
Asymp. Sig. (2-
.144
tailed)
Table 4. Test Statistics

DISCUSSION: which is the primary site of postnatal

Health outcomes for children are
influenced by the mother's diet during
pregnancy and the baby's diet throughout
infancy. The child's gut microbiome,
immune activation, is connected to both
health and sickness in children.
Breastfeeding, as opposed to formula
feeding, has been shown to increase some
taxa (i.e., a group of related organisms,

3674
such as those of a species, genus, class,
etc.), such as Bifidobacterium spp., in the
gut.18
The World Health Organization
(WHO) suggests that a baby should only
be breastfed for the first six months of his
or her life. The effects of early nutrition on
health have been thoroughly researched.
Breastmilk or infant formula are not the
only sources of nutrition at any other stage
of life. For instance, breastfeeding has
been associated with a reduced risk of
obesity and atopy in the long run, as well
as a reduced risk of infection in the
newborn period. A child's needs for
macro- and micronutrients can be met by
infant formula, but there are still a lot of
bioactive compounds in human milk that
have not been added to the formula.
Several of these components, including as
proteins and oligosaccharides, partially
enter the large intestine undigested and
thereby affect the developing lower-gut
microbiota.23
The preventive effects of
breastfeeding against diarrhea incidence,
prevalence, hospitalizations, diarrhea
mortality, and all-cause mortality have
been well documented, according to a
systematic review. The results of random
effects meta-analyses of the eighteen
studies that were included showed that
different levels of breastfeeding exposure
conferred varying degrees of protection,
with the greatest protection being
conferred by exclusive breastfeeding
among infants 0–5 months of age and by
any breastfeeding among infants and
young children 6-23 months of age. In
particular, compared to exclusive
breastfeeding among infants 0–5 months
of age (RR: 10.52) and to any
breastfeeding among children ages 6–23
months (RR: 2.18), not breastfeeding was
associated with an elevated risk of diarrhea
mortality.15
Breastfeeding improves a child's
chances of survival in the near term and is
positively linked to long-term gains in
human capital, such as better results on
intelligence tests, higher academic
accomplishment, and higher earnings. The
quantity of long-chain polyunsaturated
fatty acids in breast milk, which are crucial
for brain growth and development, may
play a role in these long-term advantages.
In addition to promoting maternal
connection, breastfeeding may also aid in
the growth of the child. The advantages of
breastfeeding for one's physical and
mental development support its promotion
and may have significant economic and
social effects.8
According to a study from
Indonesia, there is a substantial correlation
between the occurrence of diarrhea in
Indonesia and infants aged 0 to 6 months
who are not exclusively breastfed. Infants
who do not receive exclusive breastfeeding
are 2.12 times more likely to experience
diarrhea than infants who do.6 Infants aged
0 to 6 months who were exclusively
breastfed, partially breastfed, or fed infant
milk formula displayed significantly
different diarrhea incidence rates. Infants
0–6 months old who are breastfed get less
diarrhea. The first six months of a baby's
existence should be spent solely on
breastfeeding, the mother is urged. To
reduce infants' occurrence of diarrhea
between 0 and 6 months old, the Primary
Health Care sector improves public
education and promotion campaigns.10
In the current study, babies less
than 6 months had an average rate of
exclusive breastfeeding of 87.6%, and
EBF was strongly linked to a lower risk of
childhood diseases. EBF reduced the
likelihood of illness in the previous two
weeks accompanied by fever, cough, and
diarrhea. Potential confounders have no
effect on these correlations. Our research,
which is the first to look at the connection
between exclusive breastfeeding and
childhood diseases in Ethiopia, adds to the
body of knowledge already available.11
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 The composition of the gut
microbiota may be influenced by nutrition.
Infants who are formula-fed are more
likely to have Bacteroides and Clostridium
perfringens than breast-fed newborns are
to have Bifidobacteria and Clostridium
difficile. Penders et al. looked at 100
vaginally delivered, full-term babies who
had not received any antibiotics.
Compared to formula-fed newborns,
breast-fed infants had lower intestinal
concentrations of Clostridium difficile
(p=0.03) and E. coli (p=0.004).20
The article selected as a source for
this work is a selection of articles from the
years 2018 through 2022 that have been
sorted according to the inclusion criteria.
Formula feeding and diarrhea are strongly
correlated or associated. Infants who are
fed formula have a higher chance of
developing diarrhea and have a higher
frequency of diarrheal episodes. Infants
are more likely to get diarrhea if formula
milk is served in an improper or unclean
manner.17
This investigation makes it obvious
how crucial breastfeeding techniques are
to a baby's survival. Beyond its role in
lowering exposure to tainted food, which
may have contributed to the great
protection against diarrhea deaths,
exclusive breastfeeding's involvement in
the prevention of infectious diseases is
highlighted by the decrease in ARI
mortality.13 According to the reviewed
studies, nursing is a key strategy for
preventing and defending against diarrhea
in young children. The findings imply that
this approach is crucial to lowering post-
neonatal mortality and the hospitalization
rate for pediatric diarrheal illnesses.14
It can be said that there was a
connection between infants' incidence of
diarrhea and exclusive breastfeeding. The
incidence of diarrhea decreases the longer
the baby is exclusively breastfed. The
majority of mothers were found to be
housewives and less educated, according
to the survey. Therefore, it is preferable if
the nurse increases the activity of
dispensing health information on lactation
or exclusive breastfeeding to pregnant
women, especially those who are low
educated and housewives, and that all
parties support the mother for the success
of breastfeeding7.
While bottle-feeding was linked to
a higher risk of ARI in Ethiopian children,
EIBF and EBF were protective against
ARI and diarrhea. Diarrhea was less likely
to occur in babies who were primarily
breastfed. Our study implies that in order
to lessen the incidence of ARI and diarrhea
among Ethiopian children, community-
and facility-based interventions that focus
on improved IYCF practices should be
prioritized and scaled up.5
The metabolism may be affected
by early diet long after childhood, even
into maturity. The majority of infants also
drink some formula, even though breast
milk is the best source of nutrients for
them. Infant formula can still narrow the
difference between neonates who are
nursed and those who are fed formula,
despite clear advances. The reduction of
protein content, modification of the lipid
matrix, and addition of prebiotics,
probiotics, and synbiotics are highlighted
as improvements to metabolic health.19
Infants who took the baby formula
exhibited gut microbiota compositions that
were more similar to those of breastfed
infants in terms of richness and variety, as
well as greater levels of calprotectin,
compared to infants who consumed the
Standard formula. Furthermore, we
discovered that the primary bacterial
metabolic pathways of the BF and baby
formula groups were more similar to those
of the STD formula group. This shows that
adopting the novel infant formula in the
future may alter the gut microbiota's
makeup, resulting in a healthier intestinal
microbiome.21
A follow-up study by Innova 2020
revealed that both the infant formula and
the BF formula had a similar effect on the
3676
fecal microbiota, in silico metabolic
pathways, and several biochemical
indicators related to immunity after a year.
The addition of novel compounds to initial
recipes is a developing area of inquiry that
should always be assessed by randomized
clinical trials. Future intervention research
should focus on the microbiological
processes by which nutrition affects the
development of the gut during the first
year of life and beyond.22
Resuming meals as soon as feasible
can reduce intestinal osmotic pressure
brought on by infections, reduce the length
of diarrhea, and improve children's
nutritional status (evidence level A). A diet
free of lactose can also reduce the length
of diarrhea in children (evidence level B).
After receiving oral or IV rehydration
during an acute diarrheal episode, you
should as soon as possible start eating
again. Give an age-appropriate diet, let
breastfed newborns and young children
continue to nurse, and suggest low-lactose
or lactose-free formula for those receiving
formula milk. For older kids, there are no
dietary restrictions; they can eat cereals,
meat, yogurt, fruits, and vegetables.
Making sure there are enough calories is
the key goal. Supplementing with nutrition
is advised after healing. Monosaccharide-
rich foods should be avoided, including
carbonated beverages, jellies, canned
juices, sweets, and other sugary beverages.
Foods high in fat should also be avoided.16
Millions of people's lives could be
improved through breastfeeding on a
global scale. The lifelong health effects of
breastfeeding are significantly improved.
The ideal time to start breastfeeding is
within the first hour after birth, and it
should be done exclusively for at least six
months before stopping. Mother-infant
dyads need multiple tiers of assistance,
from policymakers to health professionals
to community leaders to their direct family
members, in order to meet global
breastfeeding targets.9
The annual cost to the healthcare
system from mothers who did not
breastfeed in accordance with
recommendations was calculated at
US$118 million. The average cost of the
healthcare system and out-of-pocket
expenses were $11.37 and $3.85,
respectively. This cost is made up of
US$29.98 million in non-medical patient
charges and US$88.64 million in provider
costs. The Indonesian government must
make investments in breastfeeding
protection, promotion, and support
because it might save the country's
healthcare system a lot of money if
mothers don't breastfeed as recommended.
As shown by earlier studies, in order to
fully comprehend the economic effects of
not breastfeeding in accordance with
advice, it is also necessary to take into
consideration the long-term costs
associated with cognitive impairments.12
This recent study found that the
incidence of diarrhea in infants is
especially prevalent in infants who
consume formula milk. This supports
previous studies that found that breast milk
is one of the protective factors against the
incidence of diarrhea. The statistical
results of this study showed insignificant
difference which can be caused by the lack
of research samples, so that a larger
research sample is needed in future
studies. In addition, other factors that can
cause diarrhea in infants cannot be
ignored, such as hygiene factors,
socioeconomic status, maternal education
and immune status of each infant played
an important role.
CONCLUSION:
There is an insignificant difference
in the incidence of diarrhea between
infants who consumed formula milk or
breast milk. However, in presentation, the
incidence of diarrhea is dominated by
children who consumed formula milk.
3677
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